Dangerous Love and Anti-Love Drugs: Neuroethics & Public Health Problems

By Kelsey Drewry

Kelsey Drewry is a student in the Master of Arts in Bioethics program at the Emory University Center for Ethics where she works as a graduate assistant for the Healthcare Ethics Consortium. Her current research focuses on computational linguistic analysis of health narrative data, and the use of illness narrative for informing clinical practice of supportive care for patients with neurodegenerative disorders.

The half-priced heart-shaped boxes of chocolates lining grocery store shelves serve as an undeniable marker of the recent holiday. Replete with conceptions of idyllic romance, Valentine’s Day provides an opportunity to celebrate partnership, commitment, and love. However, for those experiencing heartbreak or unrequited love, Cupid may be a harbinger of suffering rather than giddy affection.

The transition from love to pain is an incredibly common experience, and one that is formative for many. The extent of character building in heartbreak and other negative affection experiences is bounded, though, by certain types of “dangerous love”. According to Brian Earp and colleagues, this classification might include domestic abuse, pedophilia, or even jealousy-induced homicide (Earp et al 2013). The suffering associated with these cases surpasses any beneficial emotional development, leading instead to potential enduring physical and psychological harms. Instances of “dangerous love” might become the targets for “drugs that manipulate brain systems at whim to enhance or diminish our love for one another” (Young 2009, 148), which seem to be a reasonable potential product of current trajectories of neuropharmocological research.

Image courtesy of Flikr

These “anti-love” drugs are certainly beneficently intended, and may indeed be of great value in some instances. An example of neuroenhancement by diminishment, the ability of an individual to rise above the influences of attraction-causing neurochemicals and adhere instead to reason may give rise to a more morally capable person, at least in a Kantian sense. Additionally, decreasing the instances of sexual abuse and physical harms are aims that cohere with lauded public health endeavors across the globe. It is not unreasonable to consider future anti-love biotechnology as a valuable interventional tool in the effort to diminish the incidence of negative health outcomes associated with “dangerous love” on both the individual and community scale.

To this end, Earp and colleagues cite domestic violence as a promising substrate. The context is sensible, if you accept the view that love causes one to enter a state that is “literally not normal” (Marazziti et al 1999), or akin to drug or behavioral addiction (Burket and Young 2012). Under this framework, love may be understood as a neurochemically induced loss of autonomy (to some degree) that causes abuse victims to justify the sacrifice of second-order desires like leaving on account of first-order romantic bonds (Earp et al 2013). The authors proceed to lay out the framework for a “maximally promising” application of anti-love technology in human relationships under the context of domestic abuse:

1. “The love in question is clearly harmful and needs to dissolve one way or another.


2. The person would conceivably want to use the technology—and if she did want it, there would be no problematic violations of consent.


3. The technology would help the person follow her higher order goals instead of her lower order feelings.


4. It might not be psychologically possible to overcome the perilous feelings without the help of anti-love biotechnology.” (Earp et al 2013, 11-12)

Looking past some of the potentially problematic implications of language like “clearly harmful” and “higher order goals”, these measures seem to provide a reasonable first attempt at outlining a paternalistic anti-love drug administration schema. But returning to our recognition of domestic violence as a public health issue raises unique ethical refinements to even the “maximally promising” scenario for these drugs.

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Epidemiology literature shows that domestic abuse disproportionately affects vulnerable populations, specifically women, racial and ethnic minorities, and those of lower socioeconomic status (Sokoloff and Dupont 2005). In the specific “maximally promising” case of domestic abuse where the woman knows the relationship is detrimental or harmful and wants to leave, but remains only due to her autonomy-impairing neurochemical love, an anti-love drug may lead to increased harms unless applied in conjunction with other supportive measures. In their considerations, Earp and colleagues neglect the practical circumstantial issues very often associated with domestic abuse—if the victim is for some reason unable to remove themselves from the physical space of the relationship, paternalistically administering anti-love medication is eliminating any psychological capacity to tolerate the circumstance. The vulnerabilities associated with domestic violence may also predispose victims to a lack of social support, community and financial resources (Barnett and LaViolette, 1993; Iyengar and Sabik 2009; National Coalition Against Domestic Violence 2007). Removing the neurochemical basis for making some sort of transient positive meaning from an abusive relationship without providing the means for the victim to physically leave that relationship space seems incredibly irresponsible. It seems very possible that a person no longer experiencing feelings of love (or attachment, affection, lust, etc.) in these circumstances, but unable to physically escape abuse, would be predisposed to increased psychological harms—perhaps even suicidality (Cavanaugh et al 2011; Afifi et al 2009; Golding 1999; Sato-DiLorenzo and Sharps 2007).

Thus, in order for Earp’s framework to be considered ethical on the public scale, which it must if the “maximally promising” context is a preexisting concern of public health, a fifth criterion is necessary:

5. The person can conceivably remove herself from the relationship upon diminishment of love.

The justice or access emphasis of public health ethics would extend this idea further to argue that paternalistic administration of such a drug would necessitate the provision of additional supportive interventions for particularly vulnerable individuals meeting criteria 1-4 but not 5. Such a stipulation converts an act of moral permissibility (paternalistic administration of anti-love biotechnology to individuals meeting 1-4) to a moral obligation to provide community-based support in fulfillment of a positive right of assistance for individuals who do not meet criterion 5.

Now, to avoid becoming entangled in an overly specific refinement of a single speculative framework for a hypothetical drug, let us step back from my concerns with the criteria laid out by Earp and colleagues in “If I Could Just Stop Loving You: Anti-Love Biotechnology and the Ethics of a Chemical Breakup”. Arguing abstractly in such an uncertain space is unlikely to be of any benefit other than mental exercise. However, I think my refinement of Earp’s proposed criteria may be a useful case study in the specificity of neuroethical discourse, especially in the context of enhancement. The shear volume, richness, and novelty of information that exists at this intersection of neuroscience, psychology, medicine, philosophy, and public health provide a medium for incredibly nuanced discussion. Certainly, the implications of developing neurotechnologies demand careful ethical consideration distinct in kind—thus the evolution of neuroethics as a field. But becoming mired in the specific novelty of uniquely neuroethical considerations is a hazard of the discipline. It is essential that, even at its most speculative and futuristic, neuroethical discourse retains consideration of the non-neural physical and social limitations of its work. The eventual application of developing neurotechnologies to issues of public health necessitate recognition of and dialogue with the embodied context of the neuroethical question. Such considerations will both enhance the practicality of recommendations, and ensure that they are completely ethical, not just neuroethical.

References



Afifi T.O., H. MacMillan, B.J. Cox, G.J.G. Asmundson, M.B. Stein, and J. Sareen. 2009. Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females. Journal Of Interpersonal Violence 24(8):1398–1417.



Barnett O.W. and A.D. LaViolette. 1993. It Could Happen to Anyone: Why Battered Women Stay. 178 pp. Sage Publications Inc. Newbury Park, CA.



Burkett, J. and L.J. Young. 2012. The behavioral, anatomical and pharmacological parallels between social attachment, love and addiction. Psychopharmacology 244(1): 1-26.



Cavanaugh, C.E., J.T Messing, M. Del-Colle, C. O’Sullivan, and J.C. Campbell. 2011. Prevalence and Correlates of Suicidal Behavior among Adult Female Victims of Intimate Partner Violence. Suicide Life Treat Behavior (41)4: 372-383.



Earp, B.D., O.A. Wudarczyk, A. Sandberg, and J. Savulescu, 2013. If I Could Just Stop Loving You: Anti-Love Biotechnology and the Ethics of a Chemical Breakup. The American Journal of Bioethics 13(11): 3-17.



Golding, J.M. 1999. Intimate partner violence as a risk factor for mental disorders: A meta-analysis. J Fam Violence 14(2):99–132.



Iyengar, R. and L. Sabik. 2009. The Dangerous Shortage of Domestic Violence Services. Health Affairs 28(6):w1052-w1065.



Mrazziti, D., H.S. Aksiskal, A. Rossi, and G.B. Cassano. 1999. Alteration of the platelet serotonin transporter in romantic love. Psychological Medicine 29: 741-745.



National Coalition Against Domestic Violence. 2007. Domestic Violence Facts. Retrieved Feb. 21, 2017 from here.



Sato-DiLorenzo A. and P.W. Sharps. 2007. Dangerous intimate partner relationships and women's mental health and health behaviors. Issues in Mental Health Nursing 28(8):837–848.



Skoloff, N.J. and I. Dupont. 2005. Domestic Violence: Examining the Intersections of Race, Class, and Gender—An Introduction. In Domestic Violence: Readings on Race, Class, Gender, and Culture, ed. N Skoloff and C. Pratt, 1-13. New Brunswick: Rutgers University Press.



Young, L.J. 2009. Being Human: Love: Neuroscience reveals all. Nature 457(7226): 148.

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Drewry, K. (2017). Dangerous Love and Anti-Love Drugs: Neuroethics & Public Health Problems. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/02/dangerous-love-and-anti-love-drugs.html

When Neuroethicists Become Labmates

By Timothy Brown and Margaret Thompson

Timothy Brown is a doctoral student and research assistant at the University of Washington (UW). He works with the Center for Sensorimotor Neural Engineering's (CSNE) Neuroethics Trust, where he explores the broader moral and societal implications of neural engineering and neural technology use. Through the CSNE’s support, he is also embedded in the UW's BioRobotics Lab, where he investigates issues of autonomy and agency that arise for people with motor disorders who use next-generation, neurally-controlled deep-brain stimulators to manage their symptoms. 

Margaret Thompson is a doctoral student in the BioRobotics Laboratory in the Electrical Engineering department at University of Washington, Seattle; she is also president of the Student Leadership Council at the CSNE. She received her Master’s in Electrical Engineering from University of Washington in 2016 and her Bachelor’s in Engineering from Harvey Mudd College in 2014. She researches side-effect mitigation methods for deep brain stimulation, as well as how human subjects learn to use brain-computer interfaces over months to years at a time. 

Maggie Thompson and Tim Brown are graduate students at the University of Washington—Maggie studies electrical engineering, and Tim studies philosophy (in particular, neuroethics). They are both members of the Biorobotics Laboratory—a multidisciplinary lab investigating the interface between human bodies and machines. Tim serves as the lab’s “embedded ethicist” through the support of the Center for Sensorimotor Neural Engineering (CSNE).




Together, Maggie and Tim work on projects related to deep brain stimulators (or DBS, where electrodes implanted in key areas of the brain apply enough current to treat various disorders) and brain computer interfaces (or BCI, where changes in the brain are read by sensors and used to control a computer system). Their current study collects patient perspectives in “real-time” while they test the next-generation of deep brain stimulators. Their goal is to see how patients relate to their implant and how this relationship changes with different kinds of control over the implant and its parameters. 

At conferences and meetings, people are almost more interested in how Maggie and Tim collaborate than what they collaborate on. After all, there are calls for scientists and engineers to work with humanists but it’s not clear how to get started or what that collaboration looks like. In this post, Maggie and Tim continue their work (i) in a conversation answering some of the common questions people have asked about what it’s like to have an ethicist in the lab, and how to collaborate with one.

1. What were your hopes for the collaboration before you started? What concerns did you have beforehand? 

Tim Brown (TEB): When I started working with the lab, several students were working on the security of brain-computer interfaces (ii) and adaptive control of deep-brain stimulators (iii). I hoped that I would be able to contribute to one of these projects, but I would have considered myself lucky just to be able to sit in lab meetings. I was concerned at first that everyone in the lab would consider me too much of an outsider to understand their high-level discussions. I was also worried that I wouldn’t be able to explain why my work was relevant or why I should be allowed to attend lab meetings.  

Maggie Thompson (MCT): These were the same concerns that I had in joining the team despite my shared background in engineering. It's always a little daunting to join a new team. When I joined, I was excited to look at questions like "how can the philosophy and ethics work strengthen the engineering work?" and vice versa.  

One concern has been balancing my engineering research interests with this collaboration. Doctoral programs will consume all of your work, social, and personal time if given the chance, and so to carve out time for a project like this was a challenge. Another concern I had was that adding an ethics collaboration made me seem too "touchy-feely," or somehow softened my engineering in a detrimental way. This was a heightened concern since I'm a woman in a male-dominated field, so I already felt pressure to validate my technical skills without adding a humanities focus into the mix. I tried to remind myself that this collaboration would help me produce a higher quality system; if other researchers can't appreciate the merit in that, then they are the ones who need recalibrating.  

TEB: My experience is the converse of Maggie’s. Some philosophers discourage taking an empirical approach to philosophical problems—they prefer to leave data collection and analysis to the scientists. Some philosophers, then, worry that our work is not philosophy. As a person of color, this is particularly damning: many philosophers of color worry about being perceived as “real” philosophers, and some struggle to find a place in the academy (iv). But if our work is “too touchy-feely” to be engineering and “too empirical” to be philosophy, where does that leave us?   

Tim and Maggie working together in the BioRobotics lab.

2. How does your collaboration work on a daily basis? What are your main "modes of operation," or features that you think keep the collaboration running smoothly? 

MCT: Tim and I work as Ph.D. students under the program requirements of our respective departments. We each have unique research goals and our own dissertations to write. But there is overlap in our research questions, and some of Tim's research requires asking questions during experimental testing of our neural devices. Similarly, I have questions that can't be answered without tools from Tim's domain. So periodically, we meet to discuss this crossover and identify a plan of attack to answer these questions that rely on one-another's research. Between these meetings, we share papers, design and execute experiments, review data, and write articles together.  

There's no magic; Tim and I are just willing to peel time away from our individual research interests and lend it to this collaborative work. Since I'm not as familiar with some subfields that Tim works in, when he sends me a paper to read, I have to recognize that it will take some time for me to fully appreciate it, and there's no way around that. But by lending each other time for reading and discussion, we build this shared understanding for each other's work that ultimately enriches the quality of work that we produce together (v). It's definitely a process of growing your collaboration together, so it's good to start simple with a couple of shared questions and build from there.  

TEB: This is extremely important, I think. There is no a magic formula that makes this kind of collaboration work. We both have our own interests and areas of expertise and we both contribute what we can when we can. I don’t think this is any different from how labs work in general. In our case, I contribute skills and knowledge from the humanities, but I also contribute skills I picked up as a kid tinkering with computers.  

MCT: Tim also has a desk in our lab, which is important for a few reasons. First, being able to turn around and brainstorm with each other when we’re working is much more spontaneous and convenient than drafting an email every time we individually think of something. More information gets communicated and in a more organic way.  

Second, regardless of which department we are coming from, it’s important that we are mutually concerned with things like desk space issues, lab website management, how meetings are scheduled, etc. These unglamorous tasks are a place to connect in terms of shared effort. You probably all want a similar outcome such as more desk space, a clean lab environment, an effective website, etc., but some amount of time and effort has to be put in to get there. When you all work on those things, you can't help but become more of a team. Practicing shared effort is where your collaboration grows.



TEB: Yes. Unfortunately, folks in the humanities worry that they don’t have anything to contribute to a laboratory, or that they will not become a part of the community. Conversely, folks in science, technology, engineering, and mathematics fields say that they don’t know how to navigate ethical issues, or that ethics is best left to “experts.” But Maggie has personal experience thinking about the social justice implications of how people use technology at large. So, it only makes sense that she can recognize the ethical problems with the technology that she works on. And so another important part of keeping the collaboration alive is pushing through imposter syndrome and just contributing whatever we can to it.  

Close contact is the most important feature of my collaboration with my labmates. I try to meet with my labmates regularly, maintain a presence in the lab, and stay as engaged as possible. I also try make myself accountable to my labmates, and I encourage them to do the same for me. We do this by working on projects together—where I hold Maggie accountable to recent neuroethical concerns, she holds me accountable to real-world uses of BCIs.  

Some argue that when ethicists collaborate with scientists or engineers, they ought to maintain a “critical distance” from them to avoid being co-opted and used to “rubber stamp” the lab’s activities (vi). I think co-optation, however, is just the sign of a one-sided, distant relationship. After all, good colleagues don't just use one another as tokens, they take each other’s interests, projects, and methods seriously. I think we try to do that for one another, and that’s a large part of why our collaboration works. 

Image courtesy of Pixabay.

3. What do you think shows success in your collaboration? What outcomes have been good for you individually, the continuing collaboration, or both? 

TEB: I think our success can be described in terms of the unique skills and ideas we’ve developed as researchers. I find it easier to write and talk about neural technology now that I’ve seen so many people using and investigating it first-hand. Maggie is great at describing the technologies we use and the design of our experiments using them—so I’ve learned a great deal from her.  

I now feel confident doing empirical research in a multidisciplinary setting. Philosophers generally don’t pick up any of these skills in graduate school: we just learn to read texts closely and develop arguments. This collaboration has made my philosophical work better in that I don’t just work from thought-experiments. These empirical research skills also put me in a better place to “pull my weight” in the lab.  

MCT: A lot of researchers are interested in what we're doing and want to know recommendations for starting similar collaborations with their own teams. I think a lot of people recognize our type of work and collaboration as valuable even if they haven't participated in it themselves. It also gets cited as a positive aspect of our work by grant reviewers, and their opinions carry a lot of weight.  

This collaboration has helped me personally in a couple of ways. I've been able to better motivate our pursuit for neural technology. Having ethical considerations in the mix means more than just saying "this is a technical improvement," it means considering richer aspects of improvement that might be different from my preconceptions as an able-bodied engineer. I'm also gaining skills for working on multidisciplinary teams—and this isn't just the type of multidisciplinary teams where engineers talk to scientists, it's bridging larger gaps that a lot of engineers or scientists haven't had the opportunity to work across before. 

Tim and Maggie will continue this conversation later this year in a paper where they will offer concrete recommendations for successful embedded ethics efforts. By reflecting on their collaborative experience, they aim to inspire and embolden other researchers to implement similar embedded ethics approaches within their own area of study. They will also continue their research on Brain Computer Interfaces and Deep Brain Stimulators in their respective dissertations. While Maggie’s dissertation will develop methods for side-effect mitigation in closed-loop deep–brain stimulation, Tim’s dissertation will explore how different methods of controlling a deep brain stimulator effect the user’s feelings of identity, autonomy, and agency. They both anticipate graduating from their doctoral programs (Electrical Engineering and Philosophy, respectively) in 2018. 

References 

i) T Brown, M C Thompson, “When Neuroethicists Become Labmates: Obstacles, Recommendations, and (Non-)Metrics for Success,” International Neuroethics Society Annual Meeting, 2016. 

ii) Bonaci, T, J Herron, C Matlack, and H J Chizeck. “Securing the Exocortex: a Twenty-First Century Cybernetics Challenge.” 2014 IEEE Conference on Norbert Wiener in the 21st Century (21CW), 2014. 

iii) Herron, J, and H J Chizeck. “Prototype Closed-Loop Deep Brain Stimulation Systems Inspired by Norbert Wiener,” 2014 IEEE Conference on Norbert Wiener in the 21st Century (21CW), 2014 

iv) Dotson, Kristie. “How Is the Paper Philosophy?.” Comparative Philosophy 3, no. 1 (December 30, 2011). 

v) Campo-Englestein, Lisa, and Sarah B Rodriguez. “Two Chicks in a Lab with Eggs.” The Hastings Center Report 41, no. 3 (May 1, 2011): 21–23. 

vi) Barnard, D. “Reflections of a Reluctant Clinical Ethicist: Ethics Consultation and the Collapse of Critical Distance.” Theoretical Medicine and Bioethics, 1992.

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Brown, T and Thompson, M. (2017). When Neuroethicists Become Labmates. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/02/when-neuroethicists-become-labmates.html

Predicting Psychosis: Exploring Pre-Clinical Signs for Mental Illness

By Sunidhi Ramesh

This post is based on the January edition of the “Neuroethics and Neuroscience in the News” series in which Dr. Elaine Walker from Emory University discussed the ethics of assessing risk and treating brain diseases before they can be diagnosed.

This self-portrait is often used to depict the distorted

reality that many schizophrenia patients face.

(Image courtesy of Wikimedia Commons.)

“This calculator,” a 2016 headline states, “can predict your risk of developing psychotic disorders.”

Psychotic disorders, including schizophrenia and bipolar disorder with psychotic features, are characterized by noticeable deficits in “normal” behavior accompanied by hallucinations, delusions, paranoia, an early onset (the average age of onset is in the late teens or early twenties), and a derailed life course.

Because of its early age at onset, the DALY (disability adjusted life years) value for psychosis is significantly greater than that of other illnesses (1). It’s no surprise, then, that researchers are asking questions. Are there measures that can be taken to keep at-risk populations from enduring a life-hindering disability?

Fifteen years ago, the answer would be no. Today, it (just might be) yes. 

How? Researchers have recently identified patterns in pre-clinical psychotic symptoms— patterns that many psychotic patients exhibit long before they are formally diagnosed with a disorder.

In schizophrenia and other psychotic disorders that “interfere with a person’s ability to think clearly, manage emotions, make decisions and relate to others,” this pre-clinical period is called the prodromal period. During this time, patients often experience gradual disruptions in behavioral functioning (like being suspended from school or losing friends) that are accompanied by subclinical or reduced psychotic symptoms (like hallucinations and delusions).

A cloth embroidered by a schizophrenia patient.

(Image courtesy of Wikimedia Commons.)

Countries such as Australia have found ways to make the diagnosis for these pre-clinical symptoms even easier to detect through modern technology and the Internet. Websites are now in place where young people can respond to questions about psychotic symptoms that they may be experiencing and determine for themselves if they should seek mental health care. While it is important to consider the ethical grounds of allowing or encouraging potential patients to “self-diagnose” risk for psychosis (with such ethical concerns including denial of symptomology, missed diagnosis, under/overdiagnosis, and misdiagnosis), most of these tests are thought to be preliminary efforts to encourage patients to pursue mental health treatment in the first place.

In 2008, eight independent research institutions (Emory University, Harvard University, University of California Los Angeles (UCLA), University of California San Diego (UCSD), University of North Carolina Chapel Hill, University of Toronto, Yale University, and Zucker Hillside Hospital) combined efforts to research the onset and symptomology of psychotic disorders. They titled their project the North American Prodrome Longitudinal Study, or NAPLS for short.

Historically, accounts of patients with schizophrenia-like conditions began to appear in records around the 19th century (2). The word “schizophrenia” itself translates directly to “splitting of the mind,” hinting at the divisive nature of the illness and its symptoms (3).

Demographically, the disorder afflicts about 1% of the worldwide population (4). 

One patient writes:

 “Schizophrenia isn’t about what you think it is (for example, I haven’t scrawled a bunch of complex mathematical equations on a window lately). It’s loud. It is so, so loud—the voices in your head and the voices outside your head and the typing of keys and the vibrations of phones and the TV and the brewing of coffee and the footsteps behind you. Does he need to follow so closely? I’m sorry, what did you just say? I was too busy listening to the voice telling me I’m a loser.  

And my loud world can only be quieted with meds that can take two months to end up in my medicine cabinet because securing an appointment with my psychiatrist is such an ordeal. And those meds often end up causing acne or depression or diarrhea, or leave me barely able to function—let alone work efficiently. (Sometimes I need to sleep 12 hours and take two daytime naps just to stay alive.) (5)”

During her talk for the January edition of the Neuroscience and Neuroethics in the News series, Dr. Walker emphasized that NAPLS specifically has “generated an interest in the prodromal [pre-clinical] phase of illness, the stage just prior to florid psychosis.” It is in this phase, long before patients meet the DSM-5 criteria for psychotic disorders, that these individuals show a decline in normal function and the gradual onset of psychotic (among other) symptoms. Some studies suggest that the longer the period of the prodromal phase, the worse the prognosis will be for the individual down the line (6). Although the reason for this pattern is still unknown, it is apparent that early, pre-emptive interventions may be able to reduce future behavioral maladaptations and psychotic symptoms.

Schizophrenia is often characterized by strong, auditory

hallucinations-- colloquially called "hearing voices."

(Image courtesy of Deviant Art.)

How is this prodromal phase identified? Researchers at Yale University have developed a structured diagnostic interview, the Structured Interview for Prodromal Syndromes (SIPS). This assessment “evaluate[s] and monitor[s] prodromal symptoms for at-risk and comparison subjects” by quantifying characteristically attenuated psychotic symptoms, such as unusual thought content, suspiciousness, perceptual abnormalities, and disorganized communication (7). SIPS also identifies a “clinical high-risk group”— individuals in this group “have high rates of conversion to psychosis (ranging from 15-35% in most studies) over about two years.” It is under this presumption that the aforementioned psychosis calculators were developed.

From here, patients who are identified as “high risk” are admitted into programs (such as the Prodrome Assessment Research and Treatment (PART) program in San Francisco) and monitored over time. They are given resources and therapy that are aimed at helping them cope with their symptoms while better understanding what it means to have the experiences that they do.

Dr. Walker also highlighted that the standard of care in these cases does not involve antipsychotic medication. In most programs for individuals showing signs of the prodrome for psychosis, antipsychotics are only recommended when an individual meets the criteria for a psychotic disorder, and prodromal patients, by definition, do not. Basic interventions and therapy efforts (including simple monitoring, family support groups, and interventions aimed at enhancing coping mechanisms), however, have been shown to have a positive effect on high-risk patients impacted by these prodromal symptoms (8). Without a diagnosis, most high-risk patients lack a framework to refer to their illness and struggle to understand what is happening to their lives.

Nevertheless, while detecting psychosis early provides great room for intervention, mediation, and monitoring, it is important to understand that there exist potential dangers to labeling an individual as clinically “high risk” in the first place.

Schizophrenia translates to "splitting of the mind" in Greek.

(Image courtesy of Flickr.)

Among these concerns are the consequences of false negatives and false positives as well as the potential for future discrimination that these patients may face from insurance companies or from the broader world. As with all pre-clinical syndromes, the ethical implications of such errors occurring during assessment must be considered in conjunction with the research being conducted in order to ensure that both current and future patients receive the best treatment (9).

False negatives, in the context of the prodromal phase of schizophrenia, would be patients who are not identified as “high risk” through the SIPS assessment but are then diagnosed with the disorder at a later age. This type of error may lead to delays in the provision of treatment for the patient after the clinical onset of psychosis (“It can’t be any mental disorder, so maybe he is just acting up and being a typical teenager.”) or may cause varying levels of frustration with not being able to understand and label symptoms themselves or even the condition as a whole (“She doesn’t have schizophrenia, so why is she acting this way? Why is he losing his friends and wanting to drop out of school? What are these voices she is hearing?”). With the lack of a definitive prodromal assessment, patients and families may automatically assume that schizophrenia is out of the question and may subsequently “miss opportunities to intervene” (9).

False positives then, in the context of the prodromal phase of schizophrenia, would be patients who are identified as “high risk” through the SIPS assessment but are then not diagnosed with the disorder at a later age. These cases can lead to families investing in “unnecessary expensive interventions, surveillance, and treatments as well as lead to changes in the life trajectories of the patient, caregivers, and entire family” (in the case that the family makes large lifestyle changes to accommodate the patient’s newly identified condition) (9). And, if prolonged, false positive results may also give rise to larger psychosocial consequences (10).

Ultimately, to circumvent these errors, physicians and researchers are trained in appropriately debriefing patients and their families about the full range of possibilities for the subsequent developmental trajectory of individuals who meet criteria for “clinical high risk.”

(Image courtesy of Flickr.)

If such information were to become part of the individual’s medical record, some ethicists also raise the concern that patients from these pre-clinical studies may be at risk for employment and insurance discrimination, as current laws in patient protection are vague regarding the difference between “diagnosis” and pre-clinical “risk-assessments” (11). As these trials continue to increase in abundance, then, specific policy must be put into place by lawmakers (with consultation from researchers) to reduce current ambiguity and protect the rights of all patients involved.

Ultimately, as medicine moves towards early detection and disease modification, we will only see more forms of these early-detection technologies emerge not only in the realm of mental health but also for other illness in general.

During this progression, it will be critical for these ethical considerations to be explored continuously, in union with further research.

(This event was a sneak peek for an upcoming neuroscience graduate student-led symposium slated for April 28, 2017 on "The use of preclinical biomarkers for brain diseases: A Neuroethical Dilemma." This symposium will highlight preclinical detection technologies across the human lifespan, from infants to adolescents to the elderly.)

References 



1) Jones, P. B. "Adult mental health disorders and their age at onset." The British Journal of Psychiatry 202.s54 (2013): s5-s10.



2) Heinrichs RW (2003). "Historical origins of schizophrenia: two early madmen and their illness". Journal of the History of the Behavioral Sciences. 39 (4): 349–63.



3) Park, Sohee, and Katharine N. Thakkar. "' Splitting of the Mind' Revisited: Recent Neuroimaging Evidence for Functional Dysconnection in Schizophrenia and Its Relation to Symptoms." (2010): 366-368.



4) Gochman, Peter, Rachel Miller, and Judith L. Rapoport. "Childhood-onset schizophrenia: the challenge of diagnosis." Current psychiatry reports 13.5 (2011): 321.



5) "What It's Really Like To Have One Of The World's Most Stigmatized Mental Health Issues." GOOD Magazine. N.p., 04 Feb. 2017. Web. 08 Feb. 2017.



6) Yung, Alison R., and Patrick D. McGorry. "The prodromal phase of first-episode psychosis: past and current conceptualizations." Schizophrenia bulletin 22.2 (1996): 353-370.



7) Addington, Jean, et al. "North American Prodrome Longitudinal Study: a collaborative multisite approach to prodromal schizophrenia research." Schizophrenia bulletin 33.3 (2007): 665-672.



8) Kaur, Tejal, and Kristin S. Cadenhead. "Treatment implications of the schizophrenia prodrome." Behavioral Neurobiology of Schizophrenia and Its Treatment. Springer Berlin Heidelberg, 2010. 97-121.



9) Sarrett, Jennifer C., and Karen S. Rommelfanger. "Commentary: Attention to Eyes Is Present but in Decline in 2–6-Month-Old Infants Later Diagnosed with Autism." Frontiers in public health 3 (2015).



10) Brodersen, John, and Volkert Dirk Siersma. "Long-term psychosocial consequences of false-positive screening mammography." The Annals of Family Medicine 11.2 (2013): 106-115.



11) Arias, Jalayne J., and Jason Karlawish. "Confidentiality in preclinical Alzheimer disease studies When research and medical records meet." Neurology 82.8 (2014): 725-729.

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Ramesh, Sunidhi. (2017). "Predicting Psychosis: Exploring Pre-Clinical Signs for Mental Illness." The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/02/predicting-psychosis-exploring-pre.html

Space to grow? Neurological risks of moving to Mars

By Carlie Hoffman

Artistic rendition of a human colony on Mars, image

courtesy of Wikimedia Commons

Humans have been venturing into space for over 50 years. Starting in 1961 when the Russian cosmonaut Yuri Gagarin became the first human to travel into space, by 1969 Neil Armstrong, Michael Collins, and Buzz Aldrin became the first humans on the moon, and by 1998 the International Space Station had launched its first module. More recently our exploration of space has started to reach new heights, with 2011 seeing the launch of the Mars One company and its mission to produce the first human colony on Mars by 2033.

Despite our half century of space exploration, scientists have only recently started researching the effects of space travel on the brain. The question of what our brains will look like after spending an extended amount of time in space is increasingly pressing with the impending inception of the Mars colony. The first group of Mars colonists are expected to begin training later this year and will undergo 14 years of training before departing Earth in 2031 and finally landing on Mars in 2032. Though establishing a human colony on Mars will be another giant leap for mankind, will the colonists that travel to and live on Mars have the same brains as when they left Earth? 

Scientists have known for some time that space travel is hard on the body. As astronauts become farther away from Earth, the pull coming from Earth’s gravitational field becomes weaker and astronauts experience weightlessness; however, the human body is not designed to live in a weightless state. When in microgravity (the condition colloquially called “zero gravity”), the orientation information provided by Earth’s gravitational pull is lost, causing the way that you perceive your environment to alter. Furthermore, your bones decrease in density at a rate of about 1% per month while in microgravity. By comparison, elderly men and women living on Earth experience bone loss at a rate of 1-1.5% per year. Moreover, without the need for walking and standing in microgravity, the muscles lose strength and endurance. As a result, astronauts must exercise at least two hours a day while in space and must undergo rehabilitation once they return to Earth.

Scientists are also learning that space travel is hard on the brain—both psychologically and physically. Though potential astronauts undergo behavioral health exams and are screened for mental illnesses before beginning training, being in space is psychologically challenging. Astronauts are isolated in a small ship for days or months at a time, are stuck with the same small number of co-workers for the duration of their trip, and are separated from all of their friends and family back on Earth. For the Mars colonists, these challenges will be taken to the extreme: they will be traveling to a planet with no human life where they will live out the rest of their lives in the company of their fellow colonists, potentially never to see their family and friends on Earth again. Being in extreme environments, including journeys into space, can also lead to negative effects on mood and performance and increased risk for anxiety and depression (1). Furthermore, the lack of a day/night cycle in space (and the 38 extra minutes present in a day on Mars) may lead astronauts to develop altered circadian rhythms. Such circadian alterations can lead to more substantial problems than just having problems sleeping and waking up: disruptions in the circadian clock have been linked to psychiatric disorders such as depression, schizophrenia, and mania (2).

Image courtesy of Wikimedia Commons.

Being separated from life on Earth can also have a huge effect on your psyche. Some astronauts experience “break-off” while in space, a term used to describe the feeling of being disconnected from Earth and potentially from reality itself. Other astronauts feel the opposite, a global consciousness and connectedness deemed the “overview effect.” Overall, the experience of traveling into space can wreak havoc on your mental state, and these psychological effects have been noted in astronauts that have spent about six months in space. The colonists traveling to Mars are intending to establish a permanent colony where they will live for the remainder of their lives. No one has ever spent this much time in space before. In fact, the longest consecutive period of time anyone has spent in space is 438 days (a record held by the Russian cosmonaut Valery Polyakov). As the colonists prepare to spend numerous years living on Mars, we currently cannot know what changes will be wrought on their psyches (though we do have some idea of how specific regions of the brain respond to being in space). Additionally, while the colonists remain on Mars without the intent of returning to their previous lives on Earth, they will not have the opportunity to reset their brains and bodies back to the “normal state” of being on Earth. Whatever mental changes the colonists undergo while en route to and living on Mars will become their new “normal selves” for the rest of their lives.

While space travel involves many psychological challenges, equally concerning (but less well known) are the physical challenges that being in space places on the brain. Of main concern is the high level of radiation that colonists will experience on both the journey to Mars and after landing on Mars. Astronauts’ exposure to radiation while in deep space is different than our exposure to radiation while on the Earth’s surface. On Earth, we are protected from 99.9% of deep space radiation by Earth’s magnetic field; however, when astronauts leave the Earth’s magnetic field, they become exposed to much higher levels of radiation. The radiation that an astronaut will be exposed to on a round-trip to Mars is about 0.66 sievert—the equivalent of receiving a whole-body CT scan every 6 days. Once on Mars, astronauts will also experience high levels of radiation: unlike Earth, Mars does not have a global magnetic field that will protect future colonists from radiation. Exposure to radiation can lead to DNA damage. As a person’s exposure to radiation increases, their cumulative amount of DNA damage will increase, thus increasing the person’s risk of developing cancer. Studies have also indicated that there are brain-specific consequences associated with radiation exposure. One group found that whole-body radiation led to decreased cell division in the hippocampus (3)—a brain region crucial for memory and one of the few areas in the brain that undergoes neurogenesis into adulthood. There is also evidence that radiation results in altered neurotransmission in the hippocampus (4), altered neuronal architecture in the prefrontal cortex, and deficits in cognitive performance, executive function, and memory (5).

Schematic of cosmic radiation coming from the sun and the

protection offered by Earth's magnetic field.  Image courtesy

of Wikimedia Commons.

In addition to studying the specific effects of radiation on the brain, several studies have compared the brains of astronauts before and after they travel into space. A recent study found that there are significant alterations in gray matter volume after being in space and that these changes are more pronounced in astronauts who have spent longer periods of time in space. Another study performed by the National Aeronautics and Space Administration (NASA) compared the brains of Scott Kelly (who spent nearly one year in space aboard the International Space Station) and his twin brother and retired astronaut, Mark Kelly. The study is still ongoing, but thus far researchers have found altered inflammation and telomere length in samples taken from Scott Kelly after he returned from the Space Station.

Essentially, current research indicates that our brains are not built to live in space. So, as humankind moves toward living in space full-time, we are going to do so with brains that operate differently than those of people living on Earth. But, if the brain is the seat of the identity, how will being in space fundamentally change who we are? Will the people who live on Mars act, think, and feel differently than people who live on Earth? And, given the neurological changes that take place while in space, is the trip to Mars even worth it?

The Mars One company identifies three main reasons to go to Mars: 1) it is a fantastic adventure, science fiction come to life; 2) it presents the opportunity to learn more about Mars; and 3) the trip will help the progress of humankind. Other sources state that we must go to Mars to ensure the survival of our species and to improve the quality of life on Earth with the new technologies that will be used to bring humans to Mars. But, there are many reasons not to go to Mars, including the fact that the colonists cannot return to Earth and must remain with their fellow colonists on Mars for the rest of their lives, and the numerous neurological alterations that will accompany traveling to and living on Mars. Others say that we should not go to Mars because it will be expensive and we already have robots on Mars. Ultimately, whether it is worth going to Mars is still largely a matter of personal conviction: given the risk of altering your brain and never living on Earth again, would you risk going to Mars and helping humankind advance into space?

Earth and Mars, image courtesy of Wikipedia.

Mars One recognizes that there are many risks and challenges associated with establishing a Mars colony, including the loss of life and running out of money. They also acknowledge that signing up for a one way trip to Mars is not an easy choice and that creating a Mars colony will be dangerous. To combat this risk, Mars One incorporated a risk analysis protocol into its mission plan that was built with the assistance of individuals with experience at NASA (NASA assesses risk for its space missions using quantitative measures). Mars One also states that its main ethical priority is to offer the Mars colonists as high a quality of life as possible, including the ability to keep in touch with friends and family on Earth, the chance to explore Mars and expand the colony once they arrive, and the promise that more colonists will be emigrating to Mars every two years to keep the colony expanding. It is also important to note that Mars One is not the only group planning on going to Mars in the coming decades. NASA is planning on a journey to Mars by the 2030s and started working on a new rocket last summer that will carry passengers into deep space.

The main ethical imperative for the Mars One group is to ensure that every volunteer embarking on the journey to Mars is made aware of the fact that long periods of time spent in space can irrevocably alter the brain and thus potentially change their mood, personality, and self-identity. But beyond that, no one is currently being forced to be a member of the first Mars colony—all  future colonists are willingly placing themselves (and their brains) at risk. However, this will not be the case once the colonists begin trying to procreate on Mars. If the goal of the Mars One company is to plant a human colony on Mars, at some point the colonists will have to replenish their colony with new children. We currently do not know how being in space or living on Mars will impact developing fetuses, whether fetal and postnatal development of both the brain and body will be altered on Mars, and what will happen to the brains of children that grow up exclusively with the reduced gravitational pull present on Mars. Moreover, how will space-related brain changes impact the development of behaviors, mental illnesses, and all of the other identity-forming attributes to which the brain is linked?

Ultimately, creating a human colony on Mars will give humans more space to grow, but will moving into space also cause us to grow into different human beings altogether?

References



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2. Karatsoreos IN. Links between Circadian Rhythms and Psychiatric Disease. Front Behav Neurosci. 2014;8:162. Epub 2014/05/17. doi: 10.3389/fnbeh.2014.00162. PubMed PMID: 24834040; PMCID: PMC4018537.



3. Sweet TB, Hurley SD, Wu MD, Olschowka JA, Williams JP, O'Banion MK. Neurogenic Effects of Low-Dose Whole-Body HZE (Fe) Ion and Gamma Irradiation. Radiat Res. 2016;186(6):614-23. Epub 2016/12/03. doi: 10.1667/rr14530.1. PubMed PMID: 27905869; PMCID: PMC5240657.



4. Lee SH, Dudok B, Parihar VK, Jung KM, Zoldi M, Kang YJ, Maroso M, Alexander AL, Nelson GA, Piomelli D, Katona I, Limoli CL, Soltesz I. Neurophysiology of space travel: energetic solar particles cause cell type-specific plasticity of neurotransmission. Brain structure & function. 2016. Epub 2016/12/03. doi: 10.1007/s00429-016-1345-3. PubMed PMID: 27905022.



5. Parihar VK, Allen BD, Caressi C, Kwok S, Chu E, Tran KK, Chmielewski NN, Giedzinski E, Acharya MM, Britten RA, Baulch JE, Limoli CL. Cosmic radiation exposure and persistent cognitive dysfunction. Sci Rep. 2016;6:34774. Epub 2016/10/11. doi: 10.1038/srep34774. PubMed PMID: 27721383; PMCID: PMC5056393.



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Hoffman, C. (2017). Space to grow? Neurological risks of moving to Mars. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/02/space-to-grow-neurological-risks-of.html